Partnering for change

Contexts and complexities: a realist evaluation of integrated care system leadership

PURPOSE

This paper presents a realist evaluation of leadership within an integrated care system (ICS) in England. This paper aims to examine which aspects of leadership are effective, for whom, how and under what circumstances.

DESIGN/METHODOLOGY/APPROACH

Realist evaluation methodology was used, adopting prior realist review findings as the theoretical framework to refine explanations of how and why leadership within an ICS is effective. Between January and November 2023, 23 interviews with ICS leaders took place, alongside 7 meeting observations and documentary analysis. The Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) guidance informed the study design, conduct and reporting.

FINDINGS

The findings highlight two overarching infrastructural contexts influencing leadership in ICSs: the impact of the post-COVID-19 pandemic legacy and the differences between health and social care regulatory and financial environments. Findings demonstrate that ICS leaders identified a strong sense of purpose as crucial for guiding decisions and creating a psychologically safe environment for open, honest discussions, fostering calculated risk-taking. Whilst a shared vision directed priority setting, financial pressures led to siloed thinking. Leadership visibility was linked to workforce morale, with supportive leadership boosting morale amidst evolving ICS landscapes and confidence in data-driven decisions supported prevention activities. However, financial constraints hindered responsiveness and innovation in addressing health inequalities.

ORIGINALITY/VALUE

By examining ICS leadership post-COVID-19 pandemic and amidst varying regulatory and financial environments, this study contributes to the emerging literature on systems leadership and offers practical guidance for leaders navigating the complexities of integrated care.

2024 AAHA Community Care Guidelines for Small Animal Practice

Community care is a creative way of thinking about health care that mobilizes resources within a community and consists of four core principles: recognition of the urgency of access-to-care for the veterinary profession, collaboration within community networks, family-centered health care, and redefining the gold standard of care. The AAHA Community Care Guidelines for Small Animal Practice offer strategies to help busy veterinary practitioners increase access to care within their practice and community by optimizing collaborative networks. While these guidelines do not claim to provide exhaustive solutions to access-to-care issues, they propose a starting point from which private practices can explore and implement workable solutions for their community and their practice. Broadening the scope of care to reach all people with pets requires multimodal, collaborative, and creative solutions both within and outside of the veterinary profession. These solutions can begin with greater communication and collaboration between private veterinary practices and nonprofit veterinary practices, with the goal of keeping pets in their homes with their loving families as much as reasonably possible.

A self-care process model for patients with chronic noncommunicable diseases

Self-care of patients with chronic noncommunicable diseases is an essential component of contemporary healthcare. The purpose of this paper is to present a novel self-care process model and place it in the broader context of professional care. The extended Event-driven Process Chain approach to process modelling was used, focusing on a detailed overview of sequences of events, connections and activities and other elements/building blocks. A self-care process model was designed. The model is divided into two parts. The first part represents the self-care process when patients are able to manage their symptoms and be independent. The second part includes the process when patients are unable to perform self-care and/or need professional support. By identifying the essential elements of this process and incorporating them into the patients' care process, we can ensure that professional support for self-care creates a dynamic balance in the patients' ecosystems. Patients with chronic noncommunicable diseases need to make timely decisions about individual aspects of their health and seek professional help. In this way, an optimal level of health and well-being of patients can be achieved. Focusing on the patients' self-care process could also reduce treatment costs and improve the quality of life of patients. The novel designed model of the process of self-care, with all its essential elements, can be supported by digital technology, especially in the decision-making process and needs to become an important part of healthcare and long-term care systems.

Intersectoral Partnerships Between Local Governments and Health Organisations in High-Income Contexts: A Scoping Review

BACKGROUND

Local governments are the closest level of government to the communities they serve. Traditionally providing roads, rates and garbage services, they are also responsible for policy and regulation, particularly land use planning and community facilities and services that have direct and indirect impacts on (equitable) health and well-being. Partnerships between health agencies and local government are therefore an attractive proposition to progress actions that positively impact community health and well-being. Yet, the factors underpinning these partnerships across different contexts are underdeveloped, as mechanisms to improve population health and well-being.

METHODS

A scoping review was conducted to gain insight into the concepts, theories, sources, and knowledge gaps that shape partnerships between health and local governments. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines and was informed by a critical realist approach that identifies necessary, contingent and contextual factors in the literature. MEDLINE, Scopus, Web of Science, and ProQuest Central databases were searched for studies published between January 2005 and July 2021.

RESULTS

The search yielded 3472 studies, after deleting duplicates and initial title and abstract screening, 188 papers underwent full text review. Twenty-nine papers were included in the review. Key themes shaping partnerships included funding and resources; partnership qualities; governance and policy; and evaluation and measures of success. The functional, organisational and individual aspects of these themes are explored and presented in a framework.

CONCLUSION

Given that local government are the closest level of government to community, this paper provides a sophisticated roadmap that can underpin partnerships between local government and health agencies aiming to influence population health outcomes. By identifying key themes across contexts, we provide a framework that may assist in designing and evaluating evidence-informed health and local government partnerships.

Integrated care system leadership: a rapid realist review

PURPOSE

Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?

DESIGN/METHODOLOGY/APPROACH

Development of initial programme theories and associated context-mechanism-outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013).

FINDINGS

The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system.

RESEARCH LIMITATIONS/IMPLICATIONS

Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context.

ORIGINALITY/VALUE

This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems.

Family physicians collaborating for health system integration: a scoping review

BACKGROUND

In Canada, Ontario Health Teams (OHTs) are a new model for integrated healthcare. Core to OHTs are family physicians (FPs) and their ability to collaborate with other FPs and healthcare providers. Whereas the factors for intra-organizational collaboration have been well-studied, inter-organizational collaboration between FPs and other healthcare organizations as an integrated care network, are less understood. This paper aims to explore the structural factors, processes, and theoretical frameworks that support FPs' collaboration for integrated healthcare.

METHODS

A scoping review was undertaken based on Joanna Briggs Institute (JBI) methodology for scoping review and using the Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Review (PRISMA_ScR) checklist. A search for academic and relevant grey literature published between 2000-2021 was conducted across databases (MEDLINE, EMBASE, EBSCOhost).Thematic analysis was used to identify the key findings of the selected studies.

RESULTS

Thirty-two studies were included as eligible for this review. Three structural components were identified as critical to FPs' successful participation in inter-organizational partnerships: (1) shared vision/values, (2) leadership by FPs, and (3) defined decision-making procedures. Also, three processes were identified: (1) effective communication, (2) a collective sense of motivation for change, and (3) relationships built on trust. Three theoretical frameworks provided insight into collaborative initiatives: (1) Social Identity Approach, (2) framework of interprofessional collaboration, and (3) competing values framework.

CONCLUSION

FPs hold unique positions in healthcare and this review is the first to synthesize the best evidence for building collaborations between FPs and other healthcare sectors. These findings will inform collaboration strategies for healthcare integration, including with OHTs.

Transformational Change in maternity services in England: a longitudinal qualitative study of a national transformation programme 'Early Adopter'

BACKGROUND

Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.

METHODS

A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.

RESULTS

Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.

CONCLUSIONS

Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established.

How can rural community-engaged health services planning achieve sustainable healthcare system changes?

OBJECTIVES

The objectives of the Rural Site Visit Project (SV Project) were to develop a successful model for engaging all 201 communities in rural British Columbia, Canada, build relationships and gather data about community healthcare issues to help modify existing rural healthcare programs and inform government rural healthcare policy.

DESIGN

An adapted version of Boelen's health partnership model was used to identify each community's Health Care Partners: health providers, academics, policy makers, health managers, community representatives and linked sectors. Qualitative data were gathered using a semistructured interview guide. Major themes were identified through content analysis, and this information was fed back to government and interviewees in reports every 6 months.

SETTING

The 107 communities visited thus far have healthcare services that range from hospitals with surgical programs to remote communities with no medical services at all. The majority have access to local primary care.

PARTICIPANTS

Participants were recruited from the Health Care Partner groups identified above using purposeful and snowball sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

A successful process was developed to engage rural communities in identifying their healthcare priorities, while simultaneously building and strengthening relationships. The qualitative data were analysed from 185 meetings in 80 communities and shared with policy makers at governmental and community levels.

RESULTS

36 themes have been identified and three overarching themes that interconnect all the interviews, namely Relationships, Autonomy and Change Over Time, are discussed.

CONCLUSION

The SV Project appears to be unique in that it is physician led, prioritises relationships, engages all of the healthcare partners singly and jointly in each community, is ongoing, provides feedback to both the policy makers and all interviewees on a 6-monthly basis and, by virtue of its large scope, has the ability to produce interim reports that have helped inform system change.